Authorization timing and pediatric exemption

Requests for authorization will be accepted up to 10 business days after specimen collection and will be reviewed for medical necessity based on the criteria in this policy. Testing for children 6 years of age and younger is exempt from prior authorization.

• Authorization requests accepted up to 10 business days after specimen collection
• Children age 6 and under: exempt from authorization

Administrative-purpose testing excluded

Urine or other drug testing is not medically necessary when performed for administrative purposes. Examples include but are not limited to employment or pre-employment screening, continuation-of-employment requirements, school or athletic program screening, court-ordered or other medico-legal screening (unless required by state law), insurance eligibility or licensure examinations, routine physicals, or other non-clinical administrative requirements. Blanket orders, routine standing orders for all patients in a practice, and screening asymptomatic patients for administrative reasons are not supported.

• Excluded uses: employment/pre-employment, school/athletic screening, medico-legal/court-ordered (unless mandated), insurance/licensure exams, routine physicals for administrative purposes
• Also excluded: blanket orders, routine standing orders for all patients, asymptomatic screening for administrative reasons

Medical record documentation required

The medical record must document a history or clinical suspicion of illicit drug use or prescription medication misuse, noncompliance, or a high probability of non-adherence to a prescribed regimen. Documentation should include relevant clinical history, discussion of recent medication use with the member/enrollee, indications for testing, and how the test results will affect ongoing clinical management.

• Documented history or suspicion of illicit or prescription misuse, noncompliance, or high probability of non-adherence
• Record must include clinical history, discussion of recent medication/use, reason for testing, and impact on care

Presumptive testing prerequisite

A presumptive (preliminary/qualitative) test should generally be performed before ordering definitive/confirmatory testing. Definitive testing may be ordered without a prior presumptive test only when no reliable presumptive test exists for the substance in question (for example, certain synthetic cannabinoids) or when clinical circumstances make presumptive testing impractical.

• Presumptive testing is a prerequisite for definitive testing unless no reliable presumptive test exists (e.g., some synthetic cannabinoids)
• Definitive testing without a prior presumptive test is allowed when clinical circumstances or lack of reliable presumptive assays justify it

Presumptive before definitive

Definitive testing should be limited to the specific drug(s) or drug classes indicated by the presumptive test or by clinical suspicion. Reflex definitive testing following point-of-care presumptive testing is not supported when the presumptive test itself was already performed at point of care unless the coverage criteria for confirmatory testing are met and documentation supports the need for definitive identification or quantification.

• Definitive tests must target the specific drug(s)/classes indicated by the presumptive test or clinical scenario
• Reflex definitive testing after point-of-care presumptive testing is a denial risk unless criteria for confirmatory testing are met and documented